To the Editor: Drs Winston and Durbin1 have given the medical community an excellent overview
of the importance of proper restraint of children in motor vehicles. This
is a complex issue, however, and some points need further clarification.

It is important to face very young children rearward, not because of
weak neck musculature, but because of incomplete ossification of their vertebrae
and their lax connecting ligaments. In a severe crash, forward motion of the
head when the shoulders are held back can generate enough force on the neck
to pull these flexible elements apart, leaving the spinal cord as the last
link.2 Even minor stretching of the spinal
cord can result in rupture and paralysis, while complete spinal cord separation
and death can also occur.3 Readiness to
face forward cannot be determined from physical examination, but too often
health care professionals give parents poor advice based on inappropriate
criteria of muscle strength and head control. Although documented cases of
serious neck-tension injuries among forward-facing children are rare, there
are none among rear-facing children.4 It
is therefore prudent to keep children rear-facing as long as possible, but
at least until they weigh 9 kg and are 1 year old, because it is such an easy
preventive measure and the consequences of not doing so may be severe.